Habit reversal training as a treatment for refractory OCD - A case study

Dillenburger, K. (2006). Habit reversal training as a treatment for refractory OCD - A case study. European Journal of Behavior Analysis, NA, 1-27.

Published in: European Journal of Behavior Analysis

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Download date:01. Oct. 2021 EUROPEAN JOURNAL OF BEHAVIOR ANALYSIS 2006, 7, xx - xx NUMBER 1 (SUMMER 2006)  Habit reversal training as a treatment for refractory OCD – A case study

Karola Dillenburger1 Queen’s University of Belfast

Nearly 4 million American men and women from all geographic, ethnic, or economic backgrounds are diagnosed with obsessive-compulsive disorder (OCD). While a combination of cognitive (CBT) and psycho-pharmaca seems successful for 50% to 60% of patients, for intractable cases the typical recommendation is more medication or more CBT, however there is little evidence that the intensi- fied treatment regimen is successful. In this paper, habit reversal training, including awareness training, competing/other response training, self-monitoring, social support, and generalisation, was implemented with a long-term treatment-refractory OCD patient. Treatment gains and long-term maintenance indicate the potential of habit reversal procedures with these patients. Key words: Obsessional-compulsive disorder, habit reversal, relaxation, evidence-based practice, men- talism, CBT.

According to the DSM-IV the diagnosis of person is aware that their behaviour is unusual Obsessive-Compulsive Disorder (OCD) is based (BABCP, 2004). Consequently, OCD can become on two components. “Obsessions are constant, in- a source of significant embarrassment and humili- trusive, unwanted thoughts that cause distressing ation and potentially interferes with general daily emotions. Compulsions are urges to do something living tasks, academic achievement, and profes- to lessen discomfort, usually discomfort that is sional conduct. Despite the fact that individuals caused by an obsession” (American Psychiatric often spend hours engaging in OCD behaviours, Association, 2000, p.1; see Kutchins, & Kirk, most people try to conceal their symptoms and 1999 for a critique of DSM). Four to six million experience high levels of emotional distress and adults and almost one million children suffer problems in interpersonal relationships. from OCD in the US alone (The OCD Resource Obsessions are persistent thoughts, impulses, Centre of South Florida, 2004) and it is thought ideas, or images that are experienced as inappro- that at some time of their lives about 2% of priate or intrusive, and cause distress or anxiety. the population suffer from some form of OCD Typically, obsessive thoughts include fear of (British Association for Behaviour and Cognitive contamination, unwarranted concerns about Psychotherapy, BABCP, 2004). personal safety and the safety of others, inflated sense of responsibility, or trepidations of com- Symptomatology mitting violent or sexually inappropriate acts. Compulsions are repetitive behaviours, such as Obsessions and compulsions can occur as repeated unnecessary hygiene routines, avoidance often as 100 times per day and in most cases the of contact with certain household items, switching off or on of electrical appliances, locking of doors This paper has been supported by The British Academy grant or windows, re-arranging household items, or No OCG-38918 and is based on a presentation at 2nd International Convention of Association for Behavior Analysis, Brazil (2003). hoarding of certain items. Compulsions can also Reprints can be obtained from Dr Karola Dillenburger, Queen’s include mental acts, such as praying, counting, University of Belfast, 6 College Park, Belfast BT7 1LP, Northern Ireland. E-mail: [email protected] or repeated silent self-talk.   Karola Dillenburger

Epidemiology ment trap is considered typical for the commonly observed escalation of private as well as public By-and-large, it is thought that a complex OCD behaviours over time. Thus, OCD could combination of inherited biological and psycho- be considered as a habit disorder. Bienvenu et al. logical factors causes OCD, however the detail (2000) for example, suggests that OCD should of this remains participant to debate (Rachman, be considered a spectrum disorder that includes 1997; Salkovskis, 1985). For example, positron other habit disorders, such as somatoform (e.g., emission tomography (PET) scanning suggests body dysmorphic disorder and hypochondriasis) that areas in the brain that play a part in other and pathologic grooming conditions (e.g., nail neurological disorders show neurochemical ac- biting, skin picking, and ). tivity in OCD patients that differs from that of people with no mental illness or those diagnosed Treatment with other mental illness (National Institute of Health, NIH, 2001). Changes in brain activ- In the past, OCD appeared difficult or near ity have been found to coincide with treatment impossible to treat (Ferguson & Taylor, 1980; (medication and behaviour therapy) as well as Pinkerton, Hughes, & Wenrich, 1984). Tradi- clinical improvement (NIH, 2001). Further tional approaches based on psychoanalysis were evidence of brain malfunction using magnetic largely unsuccessful. However, over recent years, a resonance imaging (MRI) showed that patients combination of psycho-pharmaca and Cognitive with OCD had significantly less white matter than Behaviour Therapy (CBT) resulted in treatment controls (Jenike, Rauch, Cummings, Savage, & becoming much more effective (OCD Centre Goodman, 1996), but it remains unclear whether Los Angeles, 2004). The most commonly used brain abnormalities are cause or effect of atypical psycho-pharmaca are the kind of Selective Sero- behaviours (Goddard, 2005). tonin Re-uptake Inhibitors (SSRIs) that are used While officially OCD is classified under for patients diagnosed with depression and related anxiety disorders (American Psychiatric Associa- disorders (Vallone, 1997). While SSRIs seem to tion, 2000), cognitive theorists view OCD as a be effective for 60-70% of people diagnosed with belief disorder (O’Connor, Aardena, & Pelissier, OCD, they are usually not effective if used in 2004), in which cognitive distortions are based isolation and patients can suffer severe withdrawal on irrational and specific dysfunctional beliefs symptoms when treatment is discontinued (Za- rather than on exaggeration of normal passing jecka, Tracy, & Mitchell, 1997). thoughts. Alternatively, behaviour analysts argue CBT is widely viewed as the primary psy- from a systemic and functional analytic point chological treatment of choice for individuals of view (Keenan & Dillenburger, 2004; McNa- diagnosed with OCD (Expert Consensus Panel, mara, 1979; Novak, 1996; Sturmey, 1996) that, 1997; Ladouceur, Freeston, Gagnon, Thibodeau, similar to other habit disorders, OCD has “sig- & Dumont, 1995). The main aim of cognitive nificant operant elements maintaining it” (Thyer, aspects of CBT is to alter the client’s irrational 1997, p.732). This view is supported by clinical obsessive thoughts and beliefs so that compulsive observations that in most cases, OCD follows action becomes unnecessary (Albert Ellis Institute, a cyclical pattern in which compulsive actions 2005). The most commonly used behavioural initially lead to lessening of aversive obsessional strategy involves Exposure and Response Preven- thoughts, indicating that compulsive actions may tion (ERP; Foa & Kozak, 1986; Lindsay, Crino, be negatively reinforced by escape from obsessive & Andrews, 1997). ERP is based largely on thoughts. However, usually obsessive thoughts principles of classical conditioning, using flooding soon re-appear, indicating that compulsive ac- and/or counter-conditioning (Watson, 1924) and tions in turn may function to positively reinforce systematic de-sensitisation (Wolpe, 1958). ERP obsessive thought patterns. While the specific for ODC patients usually includes exposure to a thoughts and actions differ from one individual to hierarchy of obsessions and the requirement to another, this cyclical positive-negative reinforce- prevent responding to these thoughts with com- OCD and habit reversal  pulsive action. This is achieved through in vivo 2005), HRT is not routinely used with OCD practice during the therapy session and homework patients and there are no detailed descriptions or tasks. In cases where in vivo therapy is impossible published evidence of effectiveness. In this paper, or impractical, imaginal exposure is used for the potential of HRT with a treatment refractory which short stories based on obsessions can be ODC patient is explored. audio taped and then replayed for exposure. While about 25% of patients refuse CBT or Participant ERP, it seems effective for about 75% of those The participant was a 28-year old woman who engage in 10-20 outpatient sessions. There (Nancy), diagnosed with OCD for the past 10 is an acknowledged risk of relapse in about 25% years. Nancy lived with her husband (Andy) in of these patients. Fisher and Wells (2005) con- a new bungalow in a residential estate in a small firmed that ERP seems to be the most effective town. They met 8 years ago and married two treatment (50-60% recovery rate), however when years later. At that time Nancy had minor OCD “asymptomatic criterion is used as the index of symptoms. They had no children. outcome, ERP and have low Nancy’s OCD symptoms increased over and equivalent recovery rates (approximately recent years and, for two years prior to the be- 25%)” (p 1543). ginning of the present study, she was under the So, what is to be done to help patients who care of a psychiatrist, who prescribed high doses do not respond to this kind of treatment? While of psychopharmaca. During this time Nancy there may not be complete consensus, to-date the also received weekly CBT and ERP from a state expert advice to clinicians is to use augmented employed community psychiatric nurse (CPN), medication and/or more CBT (Expert Consensus who had received training in CBT. As part of this Panel, 1997). Although viewed as third line treat- treatment, she collected extensive frequency and ments, the expert advice in extreme cases is that intensity scores for obsessional thoughts and com- it may be necessary to use neurosurgery (internal pulsive actions (two large ring binders!). However, capsulotomy), monoamine oxidase inhibitors because these recordings were not dated, it was (MAOI), or electroconvulsive therapy (ECT), all impossible to identify daily frequency, high-risk of which, they admit, have extremely severe and time of day, or functional relations. manifest side effects (Expert Consensus Panel, 1997). This obviously is a highly unsatisfactory During the year prior to the beginning of state of affairs. There clearly is a need to find this study, depressive and suicidal thoughts be- and/or develop effective treatment for these pa- came intrusive. According to Nancy, the onset of tients that does not include more of the same (or suicidal thoughts occurred when the psychiatrist similar) CBT or highly toxic medication, electric said that OCD could not be cured and that she shock, and surgery. would have OCD for the rest of her life. Nancy Habit Reversal Training (HRT) has become explained that she did not want a life of OCD the treatment of choice for habit disorders such and could not “go on like this”. as , , and trichotillomania Due to severe depression and danger of (Miltenberger, Fuqua, & Woods, 1998). First self-harm, Nancy had been hospitalised for two developed by Azrin and Nunn (1973), this com- 3-month periods at the local hospital’s psychiat- prehensive treatment protocol is firmly based on ric inpatient unit. She had spent one month at behavioural analytic principles and includes the home between hospitalisations. On Nancy’s own following components: awareness training, com- request, she had received ECT during her second peting response training, self-monitoring, social stay; Andy had consented to this treatment only support, and generalisation training (see details reluctantly. According to Nancy, ECT had no below). In some cases not all of these components effect. Due to her acute depressive and suicidal are necessary (Woods, Miltenberger, & Lumley, thoughts, Nancy was due to be hospitalised for 1996). While not unknown in the management of a third time two days after the beginning of this ODC (Claiborn & Pedrick, 2001; OCD Action, present study. Clinical observation showed that  Karola Dillenburger

OCD symptoms caused Nancy significant distress (e.g., ‘freezer door is left open and all food will be (she spent long hours crying after each OCD destroyed’; ‘back door is left open and burglar will episode), took up more than 8 hours per day come in’; ‘put sowing needle into Andy’s sandwich (she reported constant intrusion), significantly and he eats needle’) and compulsions (e.g., check- interfered with work (Nancy had lost her job), ing freezer door is closed, cooker is switched off, had detrimental effects on her marital relationship back door is locked, fire is extinguished, sowing (Andy was planning to leave her), and hindered needles are in cupboard). Nancy was taught how normal daily functioning (Nancy often could to recognised these private as well as public behav- not leave the house). Nancy recognised that her iours and record frequency of their occurrence. obsessions and compulsions were not rational Awareness training also included teaching and were excessive. On the Yale-Brown Obsessive Nancy about contingency assessments, in other Compulsive Scale (Y-BOCS) Nancy had an over- words, to recognise antecedents, e.g., when these all score of 33 at the beginning of the study and behaviours occurred (i.e., time of day), who was therefore was placed in the extreme range (mean present, and where these behaviours occurred (i.e., for OCD population = 25.1; SD = 6; Goodman, location), and consequences, i.e., who did what Price, Rasmussen, & Mazure, 1989). afterwards. Nancy reported that most of OCD related behaviours occurred when she was in the Procedure home alone (when Andy was at work); fewer In total twelve treatment sessions were con- OCD related behaviours occurred when she was ducted; six weekly sessions were followed by four with Andy or his mother outside their home. fortnightly sessions and two monthly sessions. Nancy reported that after each OCD episode she This was followed by a period of 6 months dur- was very upset and that she spent many hours ing which Nancy sent self-monitored data to the crying; Andy and his mother were sympathetic, therapist on a monthly basis. The therapist entered patient, and compassionate. the data into the data bank and sent a printout In terms of competing response training, it is of the graphed data back to Nancy together with difficult to identify competing muscle responses, an encouraging note, such as “Thanks and well therefore relaxation was considered the most done”, “Graphs looking good!” A follow-up appropriate alternative response to be trained. visit took place after 6 months. A brief follow-up Relaxation behaviours can be carried out for meeting took place 18 months after treatment long durations and in different environments ended. Treatment took place in Nancy’s own without risk (Dillenburger & Keenan, 2003). home, to allow for immediacy, applicability, and Relaxation exercises were carried out with Nancy generalisation. on her own in each session. These exercises were Each treatment session lasted for approxi- similar to those used in hypnotic induction mately. 60 minutes. The first 50 minutes of each (Waxman, 1989). Nancy was sitting on the sofa session were spent with Nancy alone and the last and asked to make herself comfortable, close her 10 minutes with Nancy and Andy. In the first 10 eyes, slow down her breathing, and concentrate minutes of each session data collected during the on each body part in turn. Starting with the top past week were discussed with Nancy (see below of her head working down to her toes, she was for details on data collection). This was followed instructed to relax each body part in turn. When by 30 minutes of HRT exercises (see below for Nancy felt very relaxed, as indicated by her facial detailed description). A brief discussion of exer- muscles softening, her breathing slowing, her cises with Nancy (10 minutes) was followed by a arms flopping, she was asked to engage in one of joint discussion of progress and homework task her obsessive thoughts (i.e., imaginary exposure). with Nancy and Andy (10 minutes). When tensing of body was observed (e.g., making HRT treatment included the following com- a tight fist, reddening around the neck), instruc- ponents. Initially, awareness training started with tion to engage in competing/alternative responses a functional assessment interview (O’Neill, et al., (i.e., relaxation) were given (e.g., “take a deep 1997) to establish a clear definition of obsessions breath”, “relax deeper”, or “imagine a favourite OCD and habit reversal  calm place”) until Nancy showed physical signs and, if successful, she was to self-administer a of relaxation (e.g., arms flopping, redness fading) small reinforcer from the reinforce menu (e.g., while reporting to have obsessive thoughts. coffee, biscuit, TV time). If she engaged in the Furthermore, in-session reinforcement compulsive action after this, she was simply to (Kohlenberg & Tsai, 1991) was used when Nancy record, e.g., how often she ‘checked’. The cri- reported improvements in OCD related behav- terion for duration of relaxation was increased iours. For example one day in week 9, Nancy from 1 minute to 2 minutes once performance forgot to lock a window before she left the house; was stable. highly atypical behaviour due to her usual com- Data recording sheets were designed (Figure pulsion to check windows numerous times before 1) that included time and date, frequency scores leaving the house; she got very upset and cried of obsessive and compulsive behaviours, duration for hours. The therapist congratulated Nancy of relaxation, and reinforcer. and praised her for engaging in such normal and Andy was included in relation to offeringsocial ‘healthy’ behaviour (“This is a real sign of you get- support. At the end of each session Andy joined ting better. Healthy people forget to lock windows Nancy and the therapist for 10 minutes to discuss at times; people with OCD don’t”). Nancy was progress over the past week and explore plans for surprised at the therapist’s response and when the incoming week. Andy, Nancy, and therapist Nancy forgot to lock a door the following week re-viewed the graphs together (see result section). she cried for ‘only’ 2 hours. Again the therapist This involvement was important to show Andy praised Nancy for normalcy of behaviour; “Well how treatment was progressing. If and when Andy done. I forget to look my door at times. Look at noticed improvements in Nancy’s OCD related how much better you coped this time”. The next behaviours, a larger reinforcer from the reinforcer time Nancy forgot to lock a door a few weeks later, menu was self-administered (e.g., they went for she reported that she did not get upset; “I simply dinner or to the cinema). laughed at myself”. Generalisation training was carried out in Self-monitoring was agreed in relation to a relation generalised stimulus control. There were homework task. Initially, Nancy was to engage in many stimuli in the home that were not related a one-minute relaxation exercise after each obses- to OCD and Nancy learned that these could sive thought; in order to establish a baseline for become controlling stimuli for obsessions. She relaxation, no reinforcers were used during the learned to identify the early stages of these stimuli first week. Following this baseline week, Nancy gaining control over obsessive thoughts and how and Andy were asked to establish a reinforcer to prevent this from happening through using menu, a list of potential reinforcers (not costing relaxation at an early stage. For example, she re- a lot of money!). Their list included: having a cup ported never to have had obsessive thoughts about of coffee, eating a biscuit, watching a favourite TV a particular vase on the fireplace, but one day she program, listening to favourite music, or going to started obsessing that the vase would go on fire. cinema or dinner. Nancy was to engage in one- She recognised this as stimulus control and was minute relaxation after each obsessive thought able to stop this initial thought before it developed

Date and Obsessive thought Duration of Reinforcer Compulsive action time relaxation 12/10/2003 ‘freezer door open; 1 ½ minutes cup of checked 4 x food destroyed’ coffee 10.30 am ‘backdoor unlocked; 2 minutes biscuit no check 11.00 pm burglar come in’ (backdoor had been locked at 10.45 pm) Figure 1. Self-monitoring data-recording sheet  Karola Dillenburger a full-blown obsession-compulsion relation. sessions) the two-minute criterion was reached on Follow-up was conducted for 6 months after only 3 days (18%) however, duration of relaxation treatment sessions had been terminated. During never dropped below one minute. For the next 56 follow-up, data recording sheets were sent to days (fortnightly sessions) criterion was reached the therapist on a monthly basis. The therapist on 18 days (32%). During the following 56 days graphed the data and sent the updated graphs (monthly sessions) criterion was reached on 44 back to Nancy, together with a brief written note days (79%). Criterion was reached 100% during with encouraging feedback, such as “Well done”, the 135 days of treatment follow-up. “Graphs looking great”, “Keep the good work Figure 3 shows self-recorded frequencies up”. A final visit was conducted at the end of the of obsessive thoughts and compulsive actions 6-month period. throughout treatment. During baseline all obses- Eighteen months after treatment had finished sive thoughts were followed by compulsive actions a brief meeting was held to assess maintenance of (days 0-7), for the following 17 days (weekly ses- treatment gains. sions) on average 31% of obsessive thoughts were not followed by compulsive actions; during the Results next 56 days (fortnightly sessions) this increased to an average of 53% and for the following 56 Figure 2 shows average daily duration of relax- days (monthly sessions) this increased to 74% of ation after each obsessive thought. The initially obsessive thoughts not followed by compulsive agreed target criterion for duration of relaxation actions. During 135-day follow-up an average of was one-minute. During baseline, when no re- 86% of obsessive thoughts were not followed by inforcers were used, criterion was met on 3 out compulsive actions (total of 286 days). These data of 7 days. During the following 15 days when exclude 14 days during follow-up, when Nancy reinforcers were made contingent on relaxation and Andy were on holidays. criterion was reached 100%. The frequency of obsessional thoughts initially The duration criterion for relaxation was increased from a daily average of 14 during base- increased to two minutes in the forth treatment line (range 13-20) to 16 during weekly sessions session. During the following 17 days (weekly (range 9-25), however, returned to 14 during fort-

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Figure 2. Daily average duration of relaxation after each obsessive thought (days 1-22 target duration one minute; days 23-286 target duration two minutes). OCD and habit reversal  nightly sessions (range 9-22), reduced to 11 dur- Discussion ing monthly sessions (range 2-17), and reduced further to an average of 9 obsessional thoughts OCD is difficult to treat and while methods per day, during follow-up (range 7-14). have been developed that seem effective for many The frequency of compulsive actions reduced patients, for a significant number of people these during treatment from a daily average of 14 dur- treatment may not be successful. In this study, ing baseline (range 13-20), to 11 during weekly we explored the potential of HRT with a patient sessions (range 4-20), 7 during fortnightly sessions diagnosed with OCD who despite long-term (range 3-11), 3 during monthly sessions (range treatment with CBT and psychopharmaca had 0-9), and 1 during follow-up (range 0-5). not improved. In fact, symptoms were deteriorat- On the Yale-Brown Obsessive Compulsive ing and she had developed co-morbid depression Scale (Y-BOCS; Goodman, Price, Rasmussen, with suicidal tendencies. & Mazure, 1989) the average score at the end A habit reversal treatment procedure was of treatment score was 10, which is in the mild implemented with the result that frequency and range. duration of competing/alternative responses in- Furthermore, self-reported treatment out- creased, while frequency of obsessive behaviours comes included reports of suicidal thoughts hav- reduced substantially and frequency of compul- ing ceased completely, planned hospitalization sive behaviours reduced to near zero. In order to not being necessary, depressive thoughts having ensure treatment maintenance, treatment density decreased dramatically, and marital separation not was decreased relatively early, while treatment taking place. At 6-month and 18-month follow- integrity was remained. Co-morbid conditions up psychopharmacological prescriptions had been had all but disappeared at the end of treatment. reduced and treatment gains were maintained. Treatment gains were maintained over an 18- Nancy and Andy both reported rising levels of month period. self-esteem and self-efficacy, and more realistic These findings point towards important im- sense of responsibility for Nancy, and increased plications. First, HRT was highly effective in this marital happiness. case and should be further explored with patients

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Figure 3: Frequency of obsessive thoughts (top) and compulsive actions (bottom) through out treatment  Karola Dillenburger with OCD. One of the main advantages of HRT sive-compulsive disorder. Retrieved from the over ERP is that functionally speaking reinforce- Web 2/24/04. http://www.babcp.org.uk/ ment contingencies (increasing probability of Bienvenu, O..J., Samuels, J.F., Riddle, M.A., behaviour) rather than punishment contingencies Hoehn-Saric, R., Liang, K.Y., Cullen, B.A., (reducing behaviour) can be used (Dillenburger Grados, M.A., & Nestadt, G. (2000). The & Keenan, 2003). In behaviour analysis, working relationship of obsessive-compulsive disorder within reinforcement contingencies always is the to possible spectrum disorders: Results from preferred option. In this case, we concentrated on a family study. Biological Psychiatry, 48, 287- increasing alternative responses (relaxation) rather 293. then preventing target responses (as in ERP). This Claiborn, J., & Pedrick, C. (2001). The habit approach should be fully explored in a larger study change workbook. How to break bad habits and of treatment refractory patients with OCD. form good ones. Oakland, CA: New Harbinger On a more conceptual level, the question Publications. arises what exactly is going on during therapy in Dillenburger, K., & Keenan, M. (2003). Using terms of basic behavioural mechanisms (Marr, hypnosis to facilitate direct observation of 2005). All of the procedures used presently with multiple tics and self-monitoring in a typi- OCD patients are multifaceted and when used in cally developing teenager, Behavior Therapy, different research/treatment settings are open to 34, 117-125. questions regarding treatment integrity. In order Expert Consensus Panel (1997). Expert Consen- to determine the basic behavioural principles sus Panel for obsessive-compulsive disorder. that are in operation we need a comprehensive Treatment of obsessive-compulsive disorder. component analysis. While this was not the aim Journal of Clinical Psychiatry, 58, 2-72. of the present research it has become obvious that Ferguson, J.M., & Taylor, C.B. (Eds) (1980). terms such as CBT, ERP, and HRT are umbrella The comprehensive handbook of behavioural terms for a wide range of treatment components medicine. Lancaster: MTP Press Ltd. that on their own may or may not be sufficient Fisher, P.L., & Wells, A. (2005). How effective to treat OCD patients successfully. A thorough are cognitive and behavioral treatments for component analysis would prevent the use of obsessive–compulsive disorder? A clinical marketed treatment packages that all too often significance analysis. Behaviour Research and are used ‘off the shelf’ instead of being based Therapy, 43, 1543-1558. on scientific principles, functional analysis, and Foa, E. B, & Kozak, M.J. (1986). Emotional pro- individually tailored, data based decisions carried cessing of fear; Exposure to corrective informa- out by well-trained clinicians. tion. Psychological Bulletin, 99, 20-35. Goddard, S. (2005). Reflexes, learning and behav- References ior (2nd Edition), Eugen, OR: Fern Ridge Press. American Psychiatric Association (2000). Diag- Goodman, W.K., Price, L.H., Rasmussen, S.A., nostic and statistical manual of mental disorders Mazure, C., Fleischmann, C. L. Hill, G. R. (DSM), 4th edition. Washington, DC: Ameri- Heninger, xx & Charney, D. S. (1989). The can Psychiatric Press, Inc. Yale-Brown Obsessive Compulsive Scale I. Albert Ellis Institute (2005). What is REBT ? Development, use, and reliability. Archives of Retrieved from the Web 7/13/05.http://www. General Psychiatry, 46, 1006-1016. albertellis.org Jenike, M.A., Rauch, S.L., & Cummings, J.L., Azrin, N. H., & Nunn, R. G. (1973). �����Habit Savage, C.R., & Goodman, W.K. (1996). reversal: A method of eliminating nervous Recent developments in neurobiology of ob- habits and tics. Behavior Research and Therapy, sessive-compulsive disorder. Journal of Clinical 11, 619-628. Psychiatry, 57, 492-503. British Association for Behavioural and Cognitive Keenan, M., & Dillenburger, K. (2004). Why Psychotherapy (BABCP; 2004). What is obses- I’m not a cognitive psychologist. A tribute to OCD and habit reversal 

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